Document v1wE2Yxow94qN7Xv00p4OoGQq

REQUEST FOR SHIPPING - , a,, TO: Plant or Company Q lg,,H..Kc7"S Lbrt&fcS_______ _' .............................................. / Attention (\Cc m a . / Lc u a ,1a hnc.mtC i Address Tcu.r'VL.^jM Lrx_b fj~-ZZ)3 J a^22S>______________________________________________________ City Description of Shipment State R?T <V^ ^ pVp~S ^ TV1; i Zip CKCfrK " fn\jA ; o>vJ C G*. *> g/) Chemical Name L (if applicable) Haskell # Type of inner pkg_____ Total No. of containers _ mr #...r/?U) Sample VnlJwt./tyO'yCQ No. of inner pkgs. HAZARDOUS MATERIAL QNO DYES (IF YES, COMPLETE CLASSIFICATION BELOW) CHECK HAZARD CLASSIFICATION, ASTERISK SECONDARY CLASSIFICATION (SEE REVERSE SIDE FOR DEFINITIONS) EXPLOSIVES CUSS AD ETIOLOG1C AGENT ORGANIC PEROXIDE RADIOACTIVE MATERIALS (**) POISONOUS GAS, CLASS A POISONOUS LIQUID, CUSS A FUMMABLEGAS NONFUMMABLEGAS FUMMABLE LIQUID (*) (BELOW 100F) BO co OXIDIZER . FUMMABLE SOLID d CORROSIVE MATERIAL (LIQUID) o POISONOUS LIQUID, CUSS B POISONOUS SOLID, CLASS B ... CORROSIVE MATERIAL(SOLIDp'' IRRITATING MATERIAL COMBUSTIBLE LIQUID (*) 0 (BETWEEN 100F& 200) OTHERREGUUTEDMATERIAL AO BO CQ DO (*) FUSH POINT--TAG. C.C. CARCINOGEN OSHA STRONG F. ....... > ........ *. ..... .. -- .1___ . 1J:__ (* *) SHIPMENT MUST BE APPROVED BY THE RADIOLOGICAL SAFETY OFFICER MATERIALS WHICH COULD POLYMERIZE OR DECOMPOSE IN TRANSIT ARE PROHIBITED Basis for Hazard Classification (References etc.) __ _________________ ____ ;_________ ....... .... - _________ SPECIAL INSTRUCTIONS ^ ^ P Q~mo i \C% PUP x\ -0..... "cxXJc^ (ifnone indicate) ? JE. v f \L s a9 O %......... (X l. ft I'VOy.)____________________ . ' .......................... ...... ........ -------- "" '" " " ............................... SIGNED'ifjfjtcAjlt-s Qdjdujyyr'______ :- ' CHEMIST/SUPERVISOR .BUILDING - nu 4Zh f x t , REVIEWED & APPROVED TO BE COMPLETED BY COMMITTEE SHIPPING NAME .... . . , LIMITED QUANTITY YESO NOD DOT COORDINATOR OR DESIGNATE DUP040002279